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Medicine and Social Justice will have periodic postings of my comments on issues related to, well, Medicine, and Social Justice, and Medicine and Social Justice. It will also look at Health, Workforce, health systems, and some national and global priorities

Saturday, November 21, 2015

Medicare Advantage plans, also known as Medicare HMOs, or
officially as Medicare Part C, are an alternative to traditional Medicare. By
enrolling in such a plan, at additional out-of-pocket cost, the Medicare recipient
gets additional benefits that are characteristic of HMOs. This may include
smaller (or no) copayments or deductibles, coverage for things not covered by
traditional Medicare like dental care, eyeglasses, and hearing aids, and other
“advantages”. There are disadvantages, also, of course, just as in other HMOs.
Beyond cost, the main one is that there is a limited panel of providers –
doctors and hospitals – that the person can use. This is particularly an issue
for retired people who travel a lot, or may spend the winter in a warmer
climate, since these HMOs’ panels are usually in a limited geographic area.

Older “closed panel” HMOs usually had only doctors and other
providers employed by the HMO itself. There are fewer of these than there once
were; some of them, like Kaiser, are well-known. Other HMOs are “open panel”,
where any doctor can be “approved” to be part of their provider group, but many
doctors may choose not to be for reasons such as lower reimbursement or onerous
regulation. Thus, it is at least theoretically possible that a Medicare
Advantage enrollee could receive lower quality care from the doctors and
hospitals that were part of the HMO’s network than from another doctor or
hospital that might not be, but would be available to traditional Medicare
patients. In addition, some Medicare Advantage plans are open to
“dual-eligibles”, people with both Medicare and Medicaid, with Medicaid paying
the additional premium. That such programs might provide worse care than others
isnot an unreasonable concern based upon other services targeted Medicaid
patients (e.g., nursing homes) and other programs targeted specifically to low
income people.

Thus, Medicare has developed a rating
system for Medicare Advantage plans, which assigns from 1 to 5 stars based,
presumably, on carefully considered and assessed quality measures. If you want
a good plan, it would behoove you to choose one with a “5 star” rating.
Provided, of course, one is available in your area, and provided you can afford
the out-of-pocket costs, or, if you have Medicaid, it is one that Medicaid will
pay for. Unsurprisingly, many plans that have enrolled Medicaid or other
lower-income patients have had lower ratings, based on the outcomes of those
patients. The plans argue that this is because these low-income patients are
higher-risk, have more co-existing medical, mental health, and social
conditions outside of the plan’s control. Others, including the Center for
Medicare and Medicaid Services (CMS), which administers Medicare, have argued
that considering these characteristics might “give a pass” to plans that
provide lower-quality care to poor people. A similar rating system exists for
hospitals, and similar arguments have been made. As I discussed in a blog from November
10, 2013, “Does
quality of care vary by insurance status? Even Medicare? Is that OK?”, there
are legitimate arguments to be made on both sides.

Now, however, according to a
report in “Modern Healthcare” on October 21, 2015, CMS interim
administrator Andy Slavitt and his deputy administrator who runs the Center for
Medicare, Sean Cavanaugh, are considering adjusting its quality ratings for
Medicare Advantage plans based upon the pre-existing risk of the patients
enrolled. This is important to the plans, since Medicare can drop them if they
have several years of lower-than-3-star ratings. And they don’t want to be
dropped, because these plans are moneymakers, in no small part because CMS
treats them, financially, better than traditional Medicare plans (a result of
purposeful federal policy to try experiments to “privatize” Medicare). While
new criteria have not been officially announced, and would not take effect
until 2017, “The comments from Slavitt and Cavanaugh were somewhat surprising
because the CMS has previously downplayed the effects of socio-economic status
on the ratings. The agency described the effect as ‘small in most cases and not
consistently negative’ in a summary
of findings from an analysis the CMS commissioned by the RAND Corp.”

It is not only surprising, but when one considers why the
(possible) change of heart is happening, it is difficult to not consider the
financial and political clout of the insurance industry that sponsors these
programs, and the political support that such “private” Medicare-replacement
programs have. It is worth noting that
CMS has not indicated that it will consider revising the ratings for hospitals,
despite the fact that hospitals that care a higher proportion of poor and
socially disadvantaged people face the same issues. The financial penalty for
hospitals is very direct, as Medicare is not paying for readmissions which occur
within 30 days. If this seems, on its face, reasonable, consider that sometimes
even when the care provided in the hospital is of high quality, people go back
to their homes (or long-term care facilities) where it may not be. This is sometimes
a result of lack of money, lack of social support, and other stressors, but the
result is that they are more likely to be readmitted. Again, CMS has argued
that it would not want to encourage hospitals providing lower-quality care for
poor people (which certainly would be a bad thing). But if CMS penalizes
hospitals for readmissions that are outside their control, it simply encourages
hospitals to not care for low-income people, or, if they are sole providers in
their community, possibly even close their doors, and that would be a very bad
thing. Studies that have been done indeed show that readmissions are higher
when hospitals care for lower income and Medicaid patients, and that this is
not the result of poorer quality care provided when those people are
inpatients. (See “Aiming
for Fewer Hospital U-turns: The Medicare Hospital Readmission Reduction
Program” from the Kaiser Family Foundation and “Socioeconomic
status and readmissions: evidence from an urban teaching hospital” in Health Affairs.)

It is important for CMS to ensure that the care provided to
all Medicare recipients (indeed all people) by a hospital is not discriminatory
or inequitable and that all patients have access to the care they need at the
highest possible quality level. But unadjusted readmission rates are a very
crude measure of quality, and it is unreasonable for CMS to expect that
hospitals will be able to compensate for the impacts of poverty and lack of
access to preventive care and early diagnosis and treatment. It is not
unreasonable, however, for us, the American people, to expect that our
government develop and help pay for programs that ensure that people’s basic
needs for shelter, food, clothing, warmth and other social determinants of
health, as well as post-hospital care (access to primary care, home health, and
high-quality long-term care).

A single-payer health system is insufficient to address all
of these needs. But it is a good start for some of them.

The first is that mortality rates are going down for every other age and ethnic
group, as well as for whites of the same age in other developed countries (see
graphic). This means something special is happening to this population group in
the US. The second is that this increasing mortality rate is not evenly
distributed across class, but is concentrated in the lower-income,
high-school-educated or less, group of people. This begins to suggest what is special about this group: that
they are being hit hard by societal changes that particularly affect them. The
third is that the mortality rates for African-Americans, while decreasing,
still significantly exceed those of this group of midlife whites. All of these
bear further examination.

That these death rates are rising was apparently surprising
to the study’s authors, according to the New
York Times article “Death Rates Rising for Middle-Aged White
Americans, Study Finds” by Gina Kolata on November 2, 2015, which
begins with the sentence “Something
startling is happening to middle-aged white Americans.” It surprises not only
Case and Deaton, but also numerous commentators quoted in the article and in
subsequent coverage. An example cited by Kolata is Dr. Samuel Preston,
professor of sociology at the University of Pennsylvania and an expert on
mortality trends and the health of populations, whose comment was “Wow.” I guess this is an appropriate comment about
an increase in mortality rates of 134 more deaths per 100,000 people from 1999
to 2014, which Dr. Deaton says is only matched by HIV/AIDS in current time.

But the findings
are not too surprising to me. After all, Deaton and Case are economists, not
physicians or health researchers, and they came upon this data almost
serendipitously while studying other issues (such as whether areas where people
are happy have lower suicide rates). But others, those who are physicians and
health researchers, should know better. Maybe the doctors expressing surprise
are those who don’t take care of lower-income people. And the health
researchers are those who have not been reading. In a blog piece from January
14, 2014 (“More
guns and less education is a prescription for poor health”) I cite Education: It Matters More to Health than
Ever Before, published on
the Robert Wood Johnson Foundation website by researchers from the Virginia
Commonwealth University Center for Society and Health, which notes that “since
the 1990s, life expectancy has fallen for people without a high school
education, a decrease that is especially pronounced among White women.” This was
reported over a year and a half ago, and discusses a trend in place for two
decades!

Or maybe I am not
surprised because I am a doctor, and see these patients both in the clinic and
in the hospital. We do take care of lots of lower income people – those not in
the 1%, or the 20% or even the top 50%. Yes, the bottom half of the population
by income do exist, and many of them are white, and they are not doing well.
The study by Case and Deaton indicates that the causes of death that are increasing
the mortality rates in this group of people are not increases in the
“traditional” chronic diseases such as diabetes, heart disease, and cancer, but
are rather due to substance abuse (illegal drugs, prescription narcotics, and
alcohol) and suicide. This is not to say that we don’t see much illness and
many deaths from those other chronic diseases in this population; we do, and
they account for the high baseline mortality among this group, but these other
causes are the reasons for the rising mortality rate.

We have seen the
explosion of prescription opiate use in people who (like Dr. Case, as it happens)
have chronic musculoskeletal pain (despite increasing evidence that opiates are
not very effective for such pain). This often results from their work as manual
laborers, either from a specific accident or from the toll wreaked by chronic
lifting, bending, twisting, and straining. We also see increased use of
alcohol, that traditional intoxicant. While sometimes it seems that we hear
more about studies touting the benefits of a couple of glasses of wine a day,
the reality is that millions of lives are destroyed directly and indirectly by
alcohol use: those of the drinkers, those of their families, those of the
people they hit when driving drunk. And in both urban and rural areas (people
in rural areas were particularly affected by the mortality increase in Case and
Deaton’s study) the use of methamphetamine. And as the drop in standard of
living for people who used to make their living with their bodies doing jobs
that have disappeared or they can no longer physically do becomes clearly
irreversible and leads to serious depression, often compounded by chronic pain
and substance use, increasing rates of suicide.

What is only
alluded to in some of the coverage of this study is the most important point:
this is about our society failing its people. It is about the “social
determinants of health” writ large. Yes, the direct causes of the increased
death rate in this population are alcohol and drug use and depression leading
to suicide, and we do need better treatment for these conditions. But to leave
it there would be like looking at deaths from lung cancer and chronic lung
disease and concluding only that we need better drugs to treat these conditions
without considering tobacco. Our society has, for at least four decades, been
somewhere between uncaring and hostile to a huge proportion of its people. Where
once we were a land of rising expectations, where people who worked hard could
expect to have a reasonably good life, this changed beginning in the 1970s.
Jobs for those with high school educations started to become rarer, and in the
Reagan 1980s, “Great Society” programs that supported the most needy were
decimated. (For the record, the “War on Poverty” actually worked; poverty rates
went down!)

In the 1990s,
economic growth hid the concomitant growth in income disparities. With the
crashes of the tech and housing bubbles leading to severe recession in the
mid-2000s, the impact of these disparities became apparent. While there were
protests in response (e.g., the “Occupy” movement), the banks were bailed out,
the wealthy continued to grow wealthier, and working people have seen their
jobs, incomes, standards of living, health, and ultimately lives disappear.
Only the blind or willfully ignorant could have not seen this coming.

To a large
extent, then, this is an issue of class, however much “important people” decry
the use of that word. It is also an issue of race, since, as noted, mortality
rates for African-Americans (although not for Latino/Hispanics) continue to
exceed those of whites; even as they begin to converge, there is still great
disparity. Camara Jones, MD, the new president of the American Public Health
Association (APHA) uses the term “social determinants of equity” to describe
why African-Americans are so over-represented in the lower class. The current data showing that lower-income
whites are moving toward the long-term disadvantaged should not obscure this
fact, but rather remind us that white people have had a privilege that is now, for the
lowest income, being eroded.

The irony is that
many of the people in the groups reported on, and their friends and relatives
and neighbors, voted for those in Congress and their states who pursue policies
that make their situations worse. That the 1%, or 0.1%, or 0.001% (after all, 153
families have contributed 50% of all campaign donations this year!) like these
policies is understandable provided that they are not only rich but selfish,
but they alone don’t have many votes. That their money controls votes, both by
buying advertising and directly buying politicians, is undeniable. Maybe poor
people cannot contribute as much as rich people, but they can vote (most of the
time) and there are so many more of them. If we must reject “trickle down”, we
must also reject appeals for votes that are implicitly or explicitly racist;
lower income white people are not benefiting by voting for the racists. The lives and health of Americans will be
improved by improving the conditions in which they live, by an economy whose
growth is marked by more well-paying jobs, not money socked away by the
wealthiest corporations and individuals. People, of all races and ethnicities
and genders and geographical regions need dignity and opportunity and hope that
is based in reality, not false promises.

We need to treat
the diseases that affect people and cause rising mortality, but we need to
treat the conditions that lead to them even more urgently.

Sunday, November 1, 2015

The Affordable Care Act (ACA, Obamacare) has been very
successful, despite the pronouncements of doomsayers (mostly Republicans). More
than 10 million people who were previously uninsured have received coverage,
and this has dramatically increased their access to health care. However, many people
remain without health insurance, and many more are barely able to afford their
premiums or can afford only the most basic plans. These people fall largely
into three groups: those who the law was never planned to make eligible (mainly
those people who are living in this country without documents), those people
who make less than 133% of the poverty level but were not previously eligible
for Medicaid and live in states that have not opted for Medicaid expansion, and
lower-income people above 133% of poverty who have either not bought insurance
on the exchanges or bought it and have since dropped it.

The first group, those without papers, comprise over 11
million real human beings in this country, people who work and go to school
and get sick and visit our emergency rooms. That they are not even considered
in ACA or any other proposal considered politically viable is a
head-in-the-sand approach that ignores both human suffering and the cost of
providing care to them. This cost is often shifted to hospitals, doctors, and
volunteer organizations, such as the student-run Jaydoc Free Clinic in Kansas City, KS.
The work that volunteers do is admirable, like that of the people celebrated by
the first President Bush as “1000 points of light”, but it is not the way a
wealthy country should have to provide care to people.

The second group is
composed of those that the ACA intended to be covered by Medicaid expansion,
but who live in states that have opted not to expand Medicaid. Given that the
federal government would have picked up 100% of the bill for the first 4 years
and then 90% thereafter, it is financially a good deal for the states. The
reason that states like Kansas have not done so is entirely political; these
are all states with Republican governors and/or Republican-controlled
legislatures (although it does not include all of those!) whose core political
position is opposition to anything coming from President Obama. Their proposed health
plan is -- well, nothing, but they are against Obamacare, and against expanding
Medicaid, and if this seems not only mean but economically stupid, so be it.
People who in other states can access care when they need it are going without
care or showing up in extremis in ERs.
Hospitals end up footing the costs for people who could have been insured..

In Kansas, the first
hospital closure that might have been forestalled with Medicaid expansion has
occurred. Closing
of Kansas hospital adds to Medicaid expansion debate (Kansas City Star, October 18, 2015) describes the closure of Mercy
Hospital in Independence, KS. Doctors from relatively nearby towns that still
have a hospital report increases in ER visits from people from Independence.There
are many reasons that contributed to this closing, including the fact that
residents of rural areas such as Independence are older and sicker than the
national or state average, but a large proportion of them would have been
eligible for expanded Medicaid had the state implemented it. The article makes
clear that “While Medicaid expansion may not have saved Mercy Hospital, there
are some in Montgomery County who say it could save many individuals.”

The Kansas Hospital Association (KHA) has been lobbying hard
for Medicaid expansion because their members are losing money caring for
uninsured people who are covered in the states that have expanded Medicaid. These
hospitals are absorbing the impact of cuts to MediCARE which were supposed to
be offset by the decrease in the uninsured resulting from the expansion of
MediCAID, which is of course not happening in states such as Kansas, and it sees
Mercy as the first domino to fall. KHA has a lot of influence in the state
capital, Topeka, and rarely loses battles that it engages as strongly as it has
this one, but so far there has been no movement from the Governor or
legislature. While some legislators are beginning to rethink the issue: “ ‘My sense is a lot of legislators are saying
we need to have that discussion (about Medicaid expansion). We need to take a
hard look at that issue,’ said Rep. Linda Gallagher, a Lenexa Republican. ‘I do support that myself’”, others are
adamantly opposed: “’I know that’s on the
table. I don’t think any decision has been made on that,’ said Rep. Tony
Barton, a Leavenworth Republican. ‘I
think it would be moving in the wrong direction. I’ll leave it at that.’”
And well he might leave it at that, as there is really nothing he can say that
makes economic or social sense. It is a quintessential statement of opposition,
being against something because, well, he is against it.

The Star article
makes clear that Independence, KS has had, like many small towns, difficulty in
recruiting and retaining physicians, but even those towns with doctors have
hospitals with major financial challenges that could be helped by Medicaid
expansion. Dr. Doug Gruenbacher, board chair of the Kansas Academy of Family
Physicians (KAFP), an organization representing the family doctors who are the
mainstay of rural health care, practices in Quinter, KS. While Quinter has
fewer than 1000 residents (compared to Independence’s 9300), its group of
family doctors cares for people from perhaps a dozen surrounding counties. Dr.
Gruenbacher wrote a letter
to the Salina Journal (October
10, 2015) calling for Medicaid expansion. He says “I know that my hospital [Gove County Medical Center] and more importantly, my patients, would
benefit from the expansion.”

This leaves the third group of people who have had little or
no benefit from the ACA: those who have either not been able to afford to purchase
insurance on exchanges, despite subsidies, or have dropped it as a result of
rate increases by insurance companies. In “Insurance
Dropouts Present a Challenge for Health Law” (NY Times, October 11, 2015), Abby Goodnough focuses on people in
Mississippi, another states that has not expanded Medicaid. She observes that many
of those who are working and making more than 133% of poverty are eligible for
subsidies on the exchanges – indeed, 95% of Mississippians receiving coverage
this way have subsidies, the highest percentage in the nation – but
increasingly are finding the premiums more than they can afford on their tight
budgets. Sometimes people were dropped from their insurance companies simply because
they did not provide some information that the law requires to prevent
undocumented people from signing up. Sometimes they just couldn’t afford it.

The ACA prohibits insurers from denying coverage for those
with pre-existing conditions, but does not prohibit them from charging more for
that coverage. And they do. “Walter Whitlow, 56, a remodeling
contractor in Volente, Tex., said he had never seen the emails the federal
marketplace sent him asking for additional proof of income after he signed up
for a Humana plan in January. Doctors diagnosed throat cancer in February, and
in June he learned from his oncologist’s office that his monthly premium had
gone to $439 from $103 and his deductible to $4,600 from $900.” Whoops. Glitch.

Or not. The ACA
was an attempt to accommodate many political interests, and thus is a
conglomeration of different programs. Its commitment to insurance companies,
whose support seemed to be necessary to pass the bill, was to have the
“individual mandate”, so that the insurers, now required to cover everyone,
would have everyone, not just the
sickest, in their risk pool. However, beyond this, the ability of insurers to
increase premiums for the sick was projected to be a problem, but the
advantages of passing the program outweighed it. ACA is not intended to ensure
health for all, but coverage for most (except those noted above). In the
aggregate, it has been of great benefit. But for individuals, like Mr. Whitlow,
the impact has been disastrous.

It is important
to remember that this impact is not because we passed a bill that tried to
cover as many people as possible, as opponents of ACA maintain without any
data. It is because that bill did not go far enough, did not cover everyone,
did not provide sufficient protection for people from the predatory practices
of insurance companies. These are not the reasons that most ACA opponents want
to fix, although they should be fixed. Dismantling ACA will not help the people
who are described above, suffering despite this program; it would only vastly
increase their number.

But change is
necessary. We do, in fact, need a comprehensive national health program that
simply, like those of most countries, covers
everyone. Like Medicare for all. This will not solve all problems. It will
not necessarily bring doctors to rural Kansas. It will not insure quality. It
will not, in itself, completely control costs. But it is a necessary, if not
sufficient, step.

“Our mission as family
physicians is to provide care to all Kansans, not just the insured,” Dr.
Gruenbacher writes. The next step is to make sure that there are no Kansans, or
Americans, left out.